Archived: The White House

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question inadequate. At this assessment the rating has remained inadequate.

This meant people were not safe and were at risk of avoidable harm.

The service was in continued breaches of legal regulation in relation to people not receiving safe care and treatment including the management of risk, infection control, medicines, incidents and an unsafe environment. There was continued breaches relating to people not being protected from the risk of abuse, poor adherence to the Mental Capacity Act 2005, staffing and training and supervision

This service scored 25 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

At the previous 3 inspections we found accidents and incidents of distress were not completed in detail and there was a lack of analysis to look for themes and trends. We found this concern still remained. Whilst there was some analysis of incidents took place by the manager; they just noted that no themes were found. However, the analysis did not include all incidents and accidents which meant the analysis would not have been accurate. We found from care notes that further incidents of unexplained injuries or people’s distressed behaviours were not recorded as incidents. As such there was no management oversight of these. This meant there was a delay in putting in place strategies or preventative measures to reduce further risks. There was also no evidence that debriefs were taking place to understand and learn from incidents.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services

Since the last inspection no people had been admitted to the service including re-admitted from hospital. We found the manager failed to always ensure that when a person went to hospital, that the person’s GP was contacted. One person went into hospital and staff at the GP confirmed they had not been contacted about this and would have expected to have been. The manager told us they would have just assumed a representative of the GP practice would know as they briefly visited the home once a week. Care homes should inform a person’s GP when they are admitted to the hospital to ensure continuity of care, safety, and efficient management of the person’s health. This communication acts as a crucial link between primary care and hospital services, helping to ‘join the dots’ in the person’s medical history. However, the manager failed to ensure this information was shared.

The manager provided us with emails where they had contacted health care professionals in relation to concerns about people’s health. However, when we reviewed people’s care notes there was no record of these concerns or the outcome to the request for clinical support. We saw advice from a practitioner from the local GP practice that the manager should call 111 in relation to urgent concerns about a person’s health. However, there was no record that 111 was ever contacted. There was also no record of whether the person’s medical concern was addressed.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

At the previous inspections we found safeguarding incidents were not investigated appropriately or always reported to the local authority. We found on this inspection this had not improved. Whilst there were relatives that felt their loved ones were safer at the service now, we found people were not always being protected from the risk of abuse and neglect.

We saw from care notes there were incidents of unexplained bruising and injuries to people who were unable to verbally communicate how this happened due to their cognitive decline. The manager had not undertaken a detailed investigation to determined how this occurred. There was safeguarding concerns that had not been reported to the local authority safeguarding team. We saw other incidents where people had been physically and verbally aggressive to another person. This was not investigated by leaders or reported to the safeguarding authority. The manager did not consider the impact of physical, psychological and emotional abuse. This lack of recognition of what constitutes alleged abuse meant that people were being placed at risk of further abuse.

As before, leaders did not consistently adhere to the principles of the Mental Capacity Act 2005 (MCA). As a result, some people were subjected to restrictions without the appropriate legal authority. We found that people’s movements were limited using bed rails and a locked front door, and there was not always authorisation in place for these restrictions. Mental Capacity Assessments were partially completed by the manager but did not include any evidence of a best interest decision or what least restrictive options had been considered. We also identified that 1 person had been given medicine covertly (Covert administration of medicines is hiding medication in food or drink without the person’s knowledge). However, there was no evidence the person’s capacity had been assessed in relation to this or evidence of any ‘best interests’ meeting involving medical professionals and family.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

There were people that were at high risk of malnutrition and were required to be weighed weekly. This was confirmed from the manager’s analysis of people’s weights. However, we saw from records that people were only being weighed monthly. This placed people at further risk of malnutrition.

Where people were at hight risk of developing pressure sores, we saw from their care plans that the advice from the district nurse was the person needed to be repositioned every 2 hours. However, we saw from the records that staff were not consistently doing this. For example, for one person, there were 7 days when the person was only repositioned 3 times or less within a day. This placed the person at further risk of their skin deteriorating. Staff told us of this person, “They can shuffle around themselves when they are in the armchairs, so we don’t need to reposition them.” However, we did not observe the person re-position themselves during the morning of the inspection.

Other health risks associated with people’s care were not being managed well including (but not limited to) the risk of constipation, hydration, distressed behaviours and diabetes. We saw from an email from the manager that diabetes training was provided by an external professional in March 2026, yet despite this, care plans had not been updated to reflect this training to include signs to look out for should a person have high or low sugar levels and what actions to take. We also noted from their care notes that people were more often than not being given high fat, high sugar foods.

In relation to monitoring people’s fluid intake 1 member of staff told us, “[Person] is on fluid watch of 1500ml, but it’s something we work towards, rather than that’s what she has to have.” This lacked an understanding by the staff of the risks when a person was not drinking sufficient amounts. Care plans also had contradictory information relating to the risks associated with people’s care.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

As before at the previous inspections, the provider did not ensure the home environment was safe or well maintained. In 1 person’s room the radiator cover was not secured which was a risk if the person leaned on this. We found unlocked empty rooms (which was accessible to people) was being used to store equipment. 1 room had a call bell hanging down which was a ligature risk. Multiple areas of the service were poorly maintained including the furniture and furnishings in people’s rooms and the communal bathrooms.

As before, the emergency grab folder which the fire service may need to rely upon contained incorrect information about the people that lived there and the photos used for some people bared no relation to how the person looked now. There were people that no longer lived there that were showing on the residents list.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

Staff were at times working 6 or 7 back-to-back 12-hour shifts during the day based on the rotas for February and March 2026. This was despite the manager telling us, “They (staff) do no more than 5 shifts. Its only because they will be very tired. There are the odd shift they may do 1 extra shift but that’s rare.” The manager told us of waking night shifts that, “Three nights awake in a row [is the maximum], because night work is not easy, fatigue sets in, its working against the body clock.” However, we saw from the rotas that 1 member of worked a waking night shift, followed by a day shift the next day and then another night shift, another member of staff worked 5 nights in a row, and another worked 4 nights in a row. Staff working long hours was concerning, as staff did not have adequate time to rest and decompress which risks mistakes being made. This placed people at risk of harm.

Leaders had failed to ensure that staff received appropriate training and supervision in relation to their role which placed people at risk of receiving unsafe care. For example, the manager told us 1 member of staff was responsible for the maintenance at the service. However, the member of staff told us they also worked for the provider in another administrative role at a different location. There was no evidence the member of staff had received any training in relation to maintaining the safety of a care home. They also did not appear on the training matrix. The housekeeping staff had not received any ‘Control of Substances Hazardous to Health’ (COSHH) training. Under UK law, employers are required to provide this training to protect staff from risks associated with cleaning chemicals, disinfectants, clinical waste, and bodily fluids, ensuring safe usage, storage, and handling to prevent injury or illness. Of the 22 staff showing as working at the service from the rotas the manager provided, 7 did not appear on the training matrix.

Where training and supervision was provided, this was not effective in ensuring safe practices for example with moving and handling. We observed 1 member of staff assist a person to stand by pulling them up from under the person’s arm. This is considered a dangerous and outdated practice, primarily because it places immense physical strain on the person’s upper body and poses a significant risk of severe injury. One visiting professional told us, “Staff try their best, but I don’t feel they are trained sufficiently.”

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

As before, people were placed at risk as the provider had failed to ensure good infection, prevention, control practices. Whilst there had been action to address the odour of urine, areas of the service were dirty including people’s bedrooms and the communal bathrooms. There was food debris under people’s beds and drinks stains on furnishings. One bathroom had ingrained faeces around the rim of the toilet.

Staff continued not always following good infection control practices. The laundry room was not set up to ensure good infection control; there was little space for staff to place washed clothing. Other areas around the service were not clean and posed a possible infection control risk. This included degraded moving and handling equipment and sinks. The sluice room where staff needed to sterilise people’s continence aids was not in use. The manager told us the room was not required as there were no people that used commodes or urine bottles. However, we saw a urine bottle in 1 person’s room. This meant staff had no dedicated place wash people’s continence aids.

The manager told us after the inspection that they went and looked around the service and found no concerns and said, “Everything else was very clean and tidy [in the laundry]. And then even the rooms I went and checked…… it was alright.” This was particularly concerning that the provider and manager were unable to identify poor cleanliness even after we pointed it out to them.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

Whilst there were some people that received their medicine as prescribed, there were elements to the management of medicines that were unsafe. As before we found staff were not completing people’s topical creams charts. The majority that we looked at were completely blank. All the creams and liquid medication had no date of opening on them. A member of staff who administered medicine told us they knew they should do this but did not know the reason why it was required. Stating a date of opening for creams and ointments is essential to ensure patient safety, as products can become contaminated or lose effectiveness once opened.

Where staff were giving ‘as and when’ paracetamol to people, they were not recording whether they had given 1 or 2 tablets to people. Paracetamol has a maximum safe dose within a 24-hour period. Accurate recording prevents staff from exceeding this limit, which could result in severe harm to people. Where staff were applying transdermal patches to people for pain relief, they were not always accurately recording where they had placed the patch on the person. Patches can cause skin irritation or thinning if applied to the same area repeatedly. We saw from one body map that a member of staff recorded they applied the patch to the same areas on 3 consecutive occasions.

We raised a concern with the manager that they had failed to obtain accurate details of 1 person’s medicines from either the person’s GP or the pharmacy. Instead, staff were completing a Medicine Administration Record based on the medicines the person’s family were bringing into the home. The manager told us of this, “I have not personally asked [family member]” for the medicine list from the GP. Obtaining a full medication list directly from the GP is crucial to ensure the person’s safety, prevent adverse drug events, and comply with NICE standards, as relying solely on family reports can lead to dangerous inaccuracies.

During our observations we also observed a member of staff sign to state the person had taken all of their lunch medicine before they had administered it to them. The member of staff did not consider that the person may refuse the medicine. Pre-signing is considered poor practice and a breach of safety protocols. We also observed that staff were stock piling excesses of topical creams given to them from the district nurses. They were not recorded anywhere and had no prescription labels. After the inspection the manager told us, “There was no extra topical medication or anything because it was all sent back.” However, the evidence they provided of this related to people’s prescribed creams that did have prescription labels. NICE guidelines state all medicated emollients must be prescribed for a specific, named resident. Stockpiling encourages using one tube for multiple residents, which can cause cross-infection or allergic reactions.